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Research Article iMedPub Journals Journal of Hepatitis http://www.imedpub.com/ Community-Based Infectious Disease Clinics: A Tool of Engagement for Vulnerable Populations Vancouver Infectious Diseases Centre, 201-1200 Burrard St., Vancouver, BC, Canada Background: Hepatitis C virus (HCV) infection is a major international public health concern, particularly among people who inject drugs (PWID). The Downtown East Side of Vancouver (DTES) is known for a high prevalence of HCV infection. Despite available services, significant numbers of patients remain undiagnosed or lack access to potentially curative therapy. As such, there is a need to develop innovative means of recruitment into care and to assess the interest to seek care. Corresponding author: Brian Conway Methods: Community pop-up clinics (CPCs) were held at several DTES sites (including InSite, the first supervised injection facility in North America). HCV point-of-care testing was offered. Participants were also offered the opportunity to complete a survey to collect demographic information as well as data related to their knowledge about HCV treatment and readiness to receive it. A $10 incentive was offered for participation. [email protected] Results: Since the inception of the program in March 2013, 1743 individuals have been tested, of which 1125 individuals completed the survey (implemented in January 2014), with 568 (33%) infected with HCV. About 45% were unaware of a cure for this infection, but a vast majority (over 80%) would consider HCV treatment for it, if it was offered. Vol. 2 No. 1: 7 Brian Conway Syune Hakobyan, Sahand Vafadary, Tyler Raycraft, Shawn Sharma Abstract 2015 Vancouver Infectious Diseases Centre, 2011200 Burrard St., Vancouver, BC, Canada. Tel: 6046426429 Conclusions: Despite the existence of a cure for HCV infection, several barriers to HCV treatment have been identified, particularly in vulnerable populations. These barriers can exist on the levels of the patient, healthcare provider, and the health care system as a whole. There is a significant gap in HCV treatment knowledge, but a general willingness to receive care. Innovative low-threshold programs must be developed to engage those individuals in care. Keywords: Chronic hepatitis C; People who inject drugs; Treatment barriers Received: September 28, 2015; Accepted: December 08, 2015; Published: December 16, 2015 Introduction Hepatitis C virus (HCV) infection is a major international public health concern, particularly among people who inject drugs (PWID). HCV is a blood-borne viral infection of the liver affecting more than 170 million worldwide and over 300,000 in Canada, including approximately 60,000 British Columbians [1]. Approximately 20% of these individuals are co-infected with human immunodeficiency virus (HIV), adding to the burden of disease. HCV can be transmitted through unprotected sex, razors, toothbrushes, and, rarely, through vertical transmission. However, © Copyright iMedPub | the major mode of transmission is through blood via sharing of injection paraphernalia [2,3]. At a population level, injection drug use is the single most important risk factor for acquiring new HCV infections in developed countries [4]. According to the 2010 Canadian Hepatitis C Surveillance Report, 61% of HCV infection is associated with injection drug use [5]. A recent study has shown that in marginally housed adults in Vancouver, hepatic fibrosis associated with HCV infection was most commonly associated with death (hazard ratio 13.02) with none of 371 individuals who were evaluated having ever accessed potentially curative therapy for it [6]. This article is available in: http://hepatitis.imedpub.com/archive.php 1 Journal of Hepatitis The goal of treatment of HCV-infected persons is to reduce allcause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by a sustained virologic response. Historically, older HCV treatment regimens had several limitations. Older regimens included interferon injections, which were contraindicated for some individuals. Similarly, PWID were offered HCV treatment only after some period of abstinence according to old guidelines [7]. These older medications also had lower cure rates. Newer HCV medications are in some cases all-oral and offer the promise of cure in over 95% of most types of infection. Such regimens have become the mainstays of treatment guidelines in most Western countries. According to the recent evidence, treatment is recommended for all patients with chronic HCV infection, except those with short life expectancies that cannot be remediated by treating HCV, by transplantation, or by other directed therapy. Patients with short life expectancies owing to liver disease should be managed in consultation with an expert. These same guidelines recommend that even active injection drug users be considered for treatment [8,9]. Many healthcare providers are still considering re-infection as a potential issue and do not initiate HCV treatment in PWID. As we seek to implement more effective treatment modalities for HCV infection in all target populations, novel approaches to engage patients in care must be considered to ensure maximisation of the success of the intervention. This study examines the effectiveness of community pop-up clinics as a tool for engagement of such vulnerable populations. Further, we sought to assess the knowledge of available HCV treatments and the willingness to enter care amongst pop-up clinic participants. Methods We have evaluated a novel community-based approach to identify inner city residents infected with HCV and have designed a model of engagement in care as a prelude to the initiation of HCV therapy. We have termed this model the “Community Pop-Up Clinic” (CPC). These clinics are held at specific sites in Vancouver’s Downtown East Side (including InSite, the first North American supervised injection site) and are designed to evaluate up to 30 adults over a 3-hour period. Sites were selected on the basis of their location and the delivery of specific services (food, temporary shelter, etc.) for the target population. For HCV testing, we used the OraQuick® HCV Rapid Antibody Test. This is a singleuse oral swab immunoassay method that qualitatively assays the presence of HCV antibodies. The participants were instructed to refrain from eating or drinking thirty minutes before the test was administered. The result took approximately fifteen minutes to display. HCV test results were disclosed in a confidential setting. All HCV-positive individuals were offered an immediate on-site consultation with a nurse and/or a physician (Infectious Diseases specialist) to discuss opportunities for engagement in care at our multidisciplinary clinic. As an incentive for participation, a $5 gift card was given at the end of testing. This clinic would offer comprehensive medical care as well as access to trained personnel to address social needs, such as completion of forms to obtain government support or to access low cost housing. Participants were also offered the opportunity to complete a 2 2015 Vol. 2 No. 1: 7 survey to collect demographic information as well as data related to their knowledge about HCV treatment and readiness to receive it. An additional $5 gift card was provided upon completion of the survey. All procedures were reviewed and approved by a local research ethics board. All participants provided written informed consent prior to participation in the CPC. Results Since the inception of the program in March 2013, 1743 individuals have been tested, of which 1125 individuals completed the survey (implemented in January 2014). Of these, 568 individuals (33%) were found to be infected with HCV, 381 of whom agreed to complete the questionnaire. Key demographic characteristics of the surveyed population are shown in Table 1. The mean age was 52 and the population was principally men (74%). Almost 30% identified themselves as First Nations/Aboriginal. Over 55% were homeless or had unstable housing. A small minority (14%) were gainfully employed and over 50% had been incarcerated in the past. Over 40% had never injected drugs, while significant alcohol use was present in about a fifth of the population. In terms of knowledge about HCV infection, about 45% were unaware of a cure for this infection, but a vast majority (over 80%) would consider HCV treatment for it, if it was offered. Discussion Despite the existence of a cure for HCV infection, several barriers to HCV treatment have been identified, particularly in vulnerable populations [10]. These barriers can exist on the levels of the patient, healthcare provider, and the health care system as a whole. We designed the CPC model with a few objectives in mind. The first was to lower barriers to access to HCV testing. The second was to provide education about HCV infection and access to comprehensive health care in a context where all the patients’ needs would be addressed and HCV treatment could be provided. Our data suggest that the CPC program is successful and its design has allowed us to access the target population, with a prevalence rate of HCV infection of over 30%. The demographic characteristics of the study population are consistent with that of the DTES of Vancouver, suggesting that we have evaluated a representative cross-section of the population of the neighborhood as a whole [11]. Social needs with respect to housing and income assistance are considerable and will need to be addressed as part of a comprehensive plan to engage inner city populations in HCV treatment. It is interesting that a significant minority of the HCV-infected individuals we have studied claim not to have ever injected recreational drugs. The role of crack pipes in the transmission of HCV infection has been identified and merits particular attention in our group [12]. Almost half of those we interviewed were unaware of a cure for HCV infection. It will be interesting to see if specific community-based educational programs aimed at this specific point (i.e. “get tested, get cured”) will favour engagement in care going forward. In this regard, it is particularly encouraging that over 80.0% of participants would consider HCV treatment if it was offered. In conclusion, a comprehensive plan to address the HCV This article is available in: http://hepatitis.imedpub.com/archive.php 2015 Journal of Hepatitis Vol. 1 No. 1:7 Table 1 Demographics and Behavioural Characteristics of HCV Infected Participants (n=381) Evaluated at Community Pop-up Clinics. 1. Age 2. Ethnicity 3. Gender 4.Current Living Condition 5. Currently 6. Previously Incarcerated 7. Tested For HIV 8. Drinking Alcohol 9. Previous Or Current 10. Is There Cure For HCV 11. Consider HCV Treatment Average Age First Nations White Other Male Female Transgender Stable Housing Unstable Housing Homeless Working Not Working/Other Yes No Yes No Never Less Than Once A Day ≥1 Time Per Day Injected Drugs Never Injected Or Shared Yes No I Do Not Know Yes No I Do Not Know pandemic must include a systematic approach aimed at HCVinfected PWID. Our CPC program in Vancouver has been quite successful in identifying a target population that seems willing to receive treatment. Going forward, we will use the information © Under License of Creative Commons Attribution 3.0 License 52.0 y.o 114 228 43 289 90 4 181 109 105 48 307 269 97 327 52 141 167 69 311 51 290 38 54 295 40 37 29.9% 59.8% 11.3% 75.9% 23.6% 1.1% 47.5% 25.6% 27.6% 12.6% 80.6% 70.6% 25.5% 85.8% 13.6% 37.1% 43.8% 18.1% 81.6% 13.4% 76.1% 10.0% 14.2% 77.4% 10.5% 9.7% gained in our preliminary CPC evaluations to optimize our outreach programs, as well as the services we offer at our clinic to encourage HCV-infected PWID, to engage in care, and to receive curative HCV treatments in greater numbers. 3 Journal of Hepatitis References 1 Yu A, Spinelli JJ, Cook DA, Buxton JA, Krajden M (2013) Mortality among British Columbians testing for hepatitis C antibody. BMC Public Health 13: 291. 2 Mathers BM, Degenhardt L, Phillips B, Wiessing L, Hickman M, et al. (2008) Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review. Lancet 372: 17331745. 3 Shepard CW, Finelli L, Alter MJ (2005) Global epidemiology of hepatitis C virus infection. Lancet Infect Dis 5: 558-567. 4 Thursz M, Fontanet A (2014) HCV transmission in industrialized countries and resource-constrained areas. Nat Rev Gastroenterol Hepatol 11: 28-35. 5 Public Health Agency of Canada (2011) Hepatitis C in Canada: 20052010 Surveillance Report. Centre for Communicable Diseases and Infection Control, Infectious Disease Prevention and Control Branch, Public Health Agency of Canada. 6 Jones AA, Vila-Rodriguez F, Leonova O, Langheimer V, Lang DJ, et.al. 4 2015 Vol. 2 No. 1: 7 (2015) Mortality from treatable illnesses in marginally housed adults: a prospective cohort study. BMJ Open 5: e008876. 7 Sherman M, Shafran S, Burak K, Doucette K, Wong W, et al. (2007) Management of chronic hepatitis C: Consensus guidelines. Can. J. Gastroenterology 21: 25C-34C. 8 Recommendations for Testing, Managing, and Treating Hepatitis C (2015) HCV Guidance. Hepatology. 9 EASL Recommendations on Treatment of Hepatitis C (2015) European Association for the Study of the Liver. Journal of Hepatology 63: 199-236. 10 Edlin BR, Kresina TF, Raymond DB, Carden MR, Gourevitch MN, et.al. (2005) Overcoming Barriers to Prevention, Care, and Treatment of Hepatitis C in Illicit DrugUsers. Clin Infect Dis 5: S276-85. 11 Linden IA, Mar MY, Werker GR, Jang K, Krausz M (2013) Research on a vulnerable neighborhood - The Vancouver Downtown Eastside from 2001 to 2011. J Urban Health 90: 559-573. 12 Fischer B, Powis J, Cruz MF, Rudzinski K, Rehm J (2008) Hepatitis C virus transmission among oral crack users: viral detection on crack paraphernalia. Eur J Gastroenterol Hepatol 20: 29-32. This article is available in: http://hepatitis.imedpub.com/archive.php